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Peters S, Sukumar K, Blanchard S, Ramasamy A, Malinowski J, Ginex P, Senerth E, Corremans M, Munn Z, Kredo T, Remon LP, Ngeh E, Kalman L, Alhabib S, Amer YS, Gagliardi A. Trends in guideline implementation: an updated scoping review. Implement Sci 2022; 17:50. [PMID: 35870974 PMCID: PMC9308215 DOI: 10.1186/s13012-022-01223-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/11/2022] [Indexed: 11/24/2022] Open
Abstract
Background Guidelines aim to support evidence-informed practice but are inconsistently used without implementation strategies. Our prior scoping review revealed that guideline implementation interventions were not selected and tailored based on processes known to enhance guideline uptake and impact. The purpose of this study was to update the prior scoping review. Methods We searched MEDLINE, EMBASE, AMED, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews for studies published from 2014 to January 2021 that evaluated guideline implementation interventions. We screened studies in triplicate and extracted data in duplicate. We reported study and intervention characteristics and studies that achieved impact with summary statistics. Results We included 118 studies that implemented guidelines on 16 clinical topics. With regard to implementation planning, 21% of studies referred to theories or frameworks, 50% pre-identified implementation barriers, and 36% engaged stakeholders in selecting or tailoring interventions. Studies that employed frameworks (n=25) most often used the theoretical domains framework (28%) or social cognitive theory (28%). Those that pre-identified barriers (n=59) most often consulted literature (60%). Those that engaged stakeholders (n=42) most often consulted healthcare professionals (79%). Common interventions included educating professionals about guidelines (44%) and information systems/technology (41%). Most studies employed multi-faceted interventions (75%). A total of 97 (82%) studies achieved impact (improvements in one or more reported outcomes) including 10 (40% of 25) studies that employed frameworks, 28 (47.45% of 59) studies that pre-identified barriers, 22 (52.38% of 42) studies that engaged stakeholders, and 21 (70% of 30) studies that employed single interventions. Conclusions Compared to our prior review, this review found that more studies used processes to select and tailor interventions, and a wider array of types of interventions across the Mazza taxonomy. Given that most studies achieved impact, this might reinforce the need for implementation planning. However, even studies that did not plan implementation achieved impact. Similarly, even single interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if the use of frameworks, barrier identification, stakeholder engagement, and multi-faceted interventions are associated with impact. Trial registration The protocol was registered with Open Science Framework (https://osf.io/4nxpr) and published in JBI Evidence Synthesis. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01223-6.
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Kolb WH, Bade MJ, Bradberry C. Implementation of clinical practice guidelines for low back pain: A case control cohort study of knowledge translation in a multi-site healthcare organization. J Eval Clin Pract 2022; 28:288-302. [PMID: 34761482 DOI: 10.1111/jep.13633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/30/2021] [Accepted: 09/09/2021] [Indexed: 12/01/2022]
Abstract
RATIONALE The benefits of clinical practice guideline (CPG) adoption for the management of patients with back pain are well documented. However, the gap between knowledge creation and implementation remains wide with few studies documenting the iterative process of comprehensive implementation in clinical settings. The objective of this study was to improve adherent physical therapy care according to CPG's for low back pain and describe the knowledge to action (K2A) process used in a rural healthcare organization. METHODS A prospective case control cohort design was used to evaluate physical therapy provider practice changes during an 18 month intervention. Four clinical sites were selected, two of which received multifaceted educational and process interventions tailored to feedback from ongoing K2A cycle outcomes. Overall program assessment included monthly charge code reports for adherence and a pre-post survey of confidence for guideline use. Pragmatic Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) criteria were used to complete the process evaluation. RESULTS A significant difference (p < 0.001, mean difference 13.5, CI [8.5,18.5]) for charge code adherence favoured education site-1 over control site-2 after implementation. Adherence scores remained above target at both education sites 18 months after implementation. Survey differences were significant for confidence scores at education sites in use of the cognitive behavioural category, overall treatment category use and guideline communication. Process evaluation supported multifaceted interventions tailored to education sites with average cost measured by staff education time of 15.5 h per therapist trained. CONCLUSION This study extends the literature of guideline implementation by describing the unique cycles required for promoting provider behaviour change within a rural healthcare system. Adherence and confidence results suggest increased provider CPG use which was supported by the process evaluation. This study demonstrates the importance of multiple site comparisons, long-term reporting and standardized frameworks for assessment of real-world CPG implementation.
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Affiliation(s)
- William H Kolb
- Department of Physical Therapy, Radford University Waldron College of Health Professions, Radford University Carilion Campus, Roanoke, Virginia, USA
| | - Michael J Bade
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Veterans Affairs Eastern Colorado Healthcare System, Geriatric Research Education and Clinical Center, Denver, Colorado, USA
| | - Caleb Bradberry
- School of Computing and Information Sciences, Radford University Artis College of Science and Technology, Radford, Virginia, USA
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Zadro JR, O'Keeffe M, Allison JL, Lembke KA, Forbes JL, Maher CG. Effectiveness of Implementation Strategies to Improve Adherence of Physical Therapist Treatment Choices to Clinical Practice Guidelines for Musculoskeletal Conditions: Systematic Review. Phys Ther 2020; 100:1516-1541. [PMID: 32488264 DOI: 10.1093/ptj/pzaa101] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 02/26/2020] [Indexed: 02/09/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the effectiveness of implementation strategies aimed at improving the adherence of physical therapists' treatment choices to clinical practice guidelines for a range of musculoskeletal conditions. METHODS For this review, searches were performed in several databases combining terms synonymous with "practice patterns" and "physical therapy" until August 2019. The review included randomized controlled trials that investigated any intervention to improve the adherence of physical therapists' treatment choices to clinical practice guidelines or research evidence. Treatment choices assessed by surveys, audits of clinical notes, and treatment recording forms were the primary measures of adherence. Self-reported guideline adherence was the secondary measure. Three reviewers independently assessed risk of bias. Because of heterogeneity across studies, only a narrative synthesis of the results was performed. RESULTS Nine studies were included. Four demonstrated a positive effect on at least 1 measure of treatment choices for low back pain and acute whiplash. One involved a comparison with no intervention, and 3 involved a comparison with another active intervention. The interventions that demonstrated a positive effect included dissemination of clinical practice guidelines, with additional elements including interactive educational meetings (3 studies), tailored interventions and monitoring of the performance of health care delivery (1 study), peer assessment (1 study), and local opinion leaders plus educational outreach visits (1 study). CONCLUSIONS Although this review revealed limited trials evaluating interventions to increase physical therapists' use of evidence-based treatments for musculoskeletal conditions compared with no intervention, it highlighted some interventions that may be effective. IMPACT Dissemination of clinical practice guidelines, interactive educational meetings, tailored interventions and monitoring the performance of health care delivery, peer assessment, and use of local opinion leaders plus educational outreach visits should be implemented to improve physical therapists' adherence to clinical practice guidelines for a range of musculoskeletal conditions.
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Affiliation(s)
- Joshua R Zadro
- School of Public Health, Sydney Medical School, The University of Sydney, New South Wales, Australia; and Institute for Musculoskeletal Health, The University of Sydney
| | - Mary O'Keeffe
- School of Public Health, Sydney Medical School, The University of Sydney; and Institute for Musculoskeletal Health, The University of Sydney
| | - Jodie L Allison
- School of Public Health, Sydney Medical School, The University of Sydney
| | - Kirsty A Lembke
- School of Public Health, Sydney Medical School, The University of Sydney
| | - Joanna L Forbes
- School of Public Health, Sydney Medical School, The University of Sydney
| | - Christopher G Maher
- School of Public Health, Sydney Medical School, The University of Sydney; and Institute for Musculoskeletal Health, The University of Sydney
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Seven Key Themes in Physical Therapy Advice for Patients Living With Subacromial Shoulder Pain: A Scoping Review. J Orthop Sports Phys Ther 2020; 50:285-a12. [PMID: 32476583 DOI: 10.2519/jospt.2020.9152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To systematically scope the reported advice and education in physical therapy management of patients with subacromial shoulder pain, and to define key themes of the advice and education. DESIGN Scoping review. LITERATURE SEARCH We searched MEDLINE, Scopus, Web of Science, and CINAHL, with publication dates from 2007 to September 2019. STUDY SELECTION CRITERIA We included quantitative and qualitative research that reported on physical therapy interventions for subacromial shoulder pain. DATA SYNTHESIS We performed a qualitative synthesis that identified items included in patient advice and education. RESULTS Of 89 original studies included, there were 61 randomized controlled trials; 5 prospective studies; 16 nonrandomized observational intervention studies or case series; and 7 surveys, audits of physical therapy patient records, and focus groups with physical therapists. We identified 7 key themes for advice and education: exercise intensity and pain response, activity modification advice, posture advice, pain self-management advice, pathoanatomical and diagnosis information, behavioral approaches, and pain biology advice. CONCLUSION While advice focused predominantly on the local tissue pathology model, 10% of studies included information about pain neuroscience education, psychosocial factors, motor imagery, or behavior change. J Orthop Sports Phys Ther 2020;50(6):285-293. doi:10.2519/jospt.2020.9152.
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Gustavsson C, Eriksson-Crommert M. Physiotherapists' and midwives' views of increased inter recti abdominis distance and its management in women after childbirth. BMC WOMENS HEALTH 2020; 20:37. [PMID: 32103753 PMCID: PMC7045604 DOI: 10.1186/s12905-020-00907-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 02/17/2020] [Indexed: 11/23/2022]
Abstract
Background Physiotherapists and midwives in primary healthcare often encounter women with an increased separation between the two rectus abdominis muscle bellies after pregnancy, a so-called increased inter recti distance (IRD). There are few studies on the contribution of increased IRD to the explanation of post-partum health complaints, and very little guidance in the literature for health professionals on the management of increased IRD. The aim of this study was to describe how physiotherapists and midwives in primary healthcare perceive the phenomenon of increased IRD and its management in women after childbirth. Methods A purposeful sampling approach was used to select physiotherapists and midwives working in primary healthcare in three large county council healthcare organisations in Sweden having experience of encountering women with increased IRD after pregnancy. Sixteen physiotherapists and midwives participated in focus group discussions. Four focus groups with four participants in each were undertaken. A semi-structured topic guide was used to explore responses to the research questions and the discussions were analysed using qualitative content analysis. Results We identified an overarching theme: Ambivalence towards the phenomenon increased IRD and frustration over insufficient professional knowledge. The theme included three categories: Uncertainty concerning the significance of increased IRD as a causal factor for functional problems; perceived insufficient professional knowledge base for the management of increased IRD; and lack of inter-professional collaboration and teamwork in the management of patients with increased IRD. Due to sparse and somewhat contradictory research findings and absence of clinical guidelines, the health professionals lacked basic preconditions for applying an evidence-based practice concerning increased IRD. They obtained their information about increased IRD from the media and fitness coaches, and hence were somewhat unsure about what to believe regarding the phenomenon. Conclusions There was no consensus among the health professionals on how to best approach increased IRD in the clinical setting. Our findings stress the importance of more research to increase the professional knowledge base among physiotherapists and midwives. The findings highlight the urgent need for policies and clinical guidelines advising health professionals in the management of increased IRD and for facilitating inter-professional collaboration and teamwork.
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Affiliation(s)
- Catharina Gustavsson
- Center for Clinical Research Dalarna, Uppsala University, Nissers väg 3, S-79182, Falun, Sweden. .,School of Education, Health and Social Studies, Dalarna University, SE-79188, Falun, Sweden. .,Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, BMC, Box 564, SE-751 22, Uppsala, Sweden.
| | - Martin Eriksson-Crommert
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Region Örebro county, Box 1613, 701 16, Örebro, Sweden
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Morris JH, Bernhardsson S, Bird ML, Connell L, Lynch E, Jarvis K, Kayes NM, Miller K, Mudge S, Fisher R. Implementation in rehabilitation: a roadmap for practitioners and researchers. Disabil Rehabil 2019; 42:3265-3274. [PMID: 30978129 DOI: 10.1080/09638288.2019.1587013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: Despite growth in rehabilitation research, implementing research findings into rehabilitation practice has been slow. This creates inequities for patients and is an ethical issue. However, methods to investigate and facilitate evidence implementation are being developed. This paper aims to make these methods relevant and accessible for rehabilitation researchers and practitioners.Methods: Rehabilitation practice is varied and complex and occurs within multilevel healthcare systems. Using a "road map" analogy, we describe how implementation concepts and theories can inform implementation strategies in rehabilitation. The roadmap involves a staged journey that considers: the nature of evidence; context for implementation; navigation tools for implementation; strategies to facilitate implementation; evaluation of implementation outcomes; and sustainability of implementation. We have developed a model to illustrate the journey, and four case studies exemplify implementation stages in rehabilitation settings.Results and Conclusions: Effective implementation strategies for the complex world of rehabilitation are urgently required. The journey we describe unpacks that complexity to provide a template for effective implementation, to facilitate translation of the growing evidence base in rehabilitation into improved patient outcomes. It emphasizes the importance of understanding context and application of relevant theory, and highlights areas which should be targeted in new implementation research in rehabilitation.Implications for rehabilitationEffective implementation of research evidence into rehabilitation practice has many interconnected steps and a roadmap analogy is helpful in defining them.Understanding context for implementation is critically important and using theory can facilitate development of understanding.Research methods for implementation in rehabilitation should be carefully selected and outcomes should evaluate implementation success as well as clinical change.Sustainability requires regular revisiting of the interconnected steps.
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Affiliation(s)
- Jacqui H Morris
- School of Nursing and Health Sciences, University of Dundee, Dundee, UK
| | - Susanne Bernhardsson
- Närhälsan Research and Development Primary Health Care, Gothenburg, Sweden.,The Sahlgrenska Academy Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Marie-Louise Bird
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
| | - Louise Connell
- School of Health Sciences, University of Central Lancashire, Preston, UK
| | - Elizabeth Lynch
- Adelaide Nursing School, University of Adelaide, Adelaide, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Victoria, Australia.,NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Victoria, Australia
| | - Kathryn Jarvis
- School of Health Sciences, University of Central Lancashire, Preston, UK
| | - Nicola M Kayes
- Centre for Person Centred Research, Auckland University of Technology, Auckland, New Zealand
| | - Kim Miller
- Evidence Centre, Sunny Hill Health Centre for Children, Vancouver, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Suzie Mudge
- Centre for Person Centred Research, Auckland University of Technology, Auckland, New Zealand
| | - Rebecca Fisher
- School of Medicine, University of Nottingham, Nottingham, UK
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Oostendorp RA, Elvers H, van Trijffel E, Rutten GM, Scholten-Peeters GG, Heijmans M, Hendriks E, Mikolajewska E, De Kooning M, Laekeman M, Nijs J, Roussel N, Samwel H. Has the quality of physiotherapy care in patients with Whiplash-associated disorders (WAD) improved over time? A retrospective study using routinely collected data and quality indicators. Patient Prefer Adherence 2018; 12:2291-2308. [PMID: 30519001 PMCID: PMC6233472 DOI: 10.2147/ppa.s179808] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To develop valid quality indicators (QIs) for physiotherapy care based on best available evidence, and to use these QIs to explore trends in the quality of physiotherapy care of patients with Whiplash-associated disorders (WAD) using guideline-based routinely collected data (RCD) gathered between 1996 and 2011. MATERIALS AND METHODS The study consisted of two phases: 1) development of QIs and 2) analysis of patient records. A set of QIs was developed based on recommendations in the scientific literature and the Dutch Clinical Practice Guideline (CPG) "Physiotherapy Management and WAD". QIs were expressed as percentages, allowing target performance levels to be defined (≥80% or ≤30% depending on whether desired performance required a high or low score on a QI). We then analyzed WAD patient data (N = 810) collected over a period of 16 years in two physiotherapy practices, separating patients into two groups defined as before (Group A 1996-2002; n = 353) and after (Group B 2003-2011; n = 457) implementation and transition to the Dutch CPG "Physiotherapy Management and WAD". RESULTS Using an iterative process and input from both experts and users, 28 QIs were developed and subsequently classified per step of the clinical reasoning process for physiotherapy care. Based on 16 years of RCD, we found that the clinical reasoning process differed significantly (P ≤ 0.05) between the groups, in favor of Group B. Twelve of the 25 indicators (48.0%) in Group A and 19 of 26 indicators (73.1%) in Group B met predetermined performance targets. The number of target indicators also differed significantly between groups, favoring Group B (P ≤ 0.05). CONCLUSION A preliminary set of novel QIs was developed. Using RCD and these QIs, we conclude that physiotherapy care in our study setting improved over the period 1996-2011. Furthermore, the QIs met the performance targets set for the clinical reasoning process after the transition to the Dutch CPG "Physiotherapy Management and WAD".
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Affiliation(s)
- Rob Ab Oostendorp
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands,
- Department of Manual Therapy, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium,
- Pain in Motion International Research Group, Free University Brussels, Brussels, Belgium,
- Practice Physiotherapy and Manual Therapy, Heeswijk-Dinther, the Netherlands,
| | - Hans Elvers
- Department of Public Health and Research, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
- Methodological Health-Skilled Institute, Beuningen, the Netherlands
| | - Emiel van Trijffel
- SOMT University of Physiotherapy, Amersfoort, the Netherlands
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Free University Brussels, Brussels, Belgium
| | - Geert M Rutten
- Institute of Health Studies, Faculty of Health and Social Studies, HAN University of Applied Science, Nijmegen, the Netherlands
- Faculty of Science and Engineering, University College Venlo, Maastricht University, Maastricht, the Netherlands
| | - Gwendolyne Gm Scholten-Peeters
- Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Marcel Heijmans
- Practice Physiotherapy and Manual Therapy, Heeswijk-Dinther, the Netherlands,
| | - Erik Hendriks
- Department of Epidemiology, Center of Evidence-Based Physiotherapy, Maastricht University, Maastricht, the Netherlands
- Practice Physiotherapy 'Klepperheide', Druten, the Netherlands
| | - Emilia Mikolajewska
- Department of Physiotherapy, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
- Neurocognitive Laboratory, Centre for Modern Interdisciplinary Technologies, Nicolaus Copernicus University, Toruń, Poland
| | - Margot De Kooning
- Pain in Motion International Research Group, Free University Brussels, Brussels, Belgium,
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Free University Brussels, Brussels, Belgium
- Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium
| | - Marjan Laekeman
- Department of Nursing Sciences, Faculty of Health, University Witten/Herdecke, Witten, Germany
| | - Jo Nijs
- Pain in Motion International Research Group, Free University Brussels, Brussels, Belgium,
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Free University Brussels, Brussels, Belgium
- Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium
| | - Nathalie Roussel
- Department of Rehabilitation Sciences and Physiotherapy (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | - Han Samwel
- Department of Medical Psychology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
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